Conditional Payment / Medicare Lien Services
The Medicare Secondary Payer (MSP) Act is a federal law that governs the coordination of benefits when an individual has Medicare coverage as well as another primary source of health coverage.
The primary purpose of the MSP Act is to ensure that Medicare does not pay for healthcare services that should be covered by another insurance or payment source, making Medicare the 'secondary payer' in such situations.
To facilitate coordination of benefits and the recovery of conditional payments, there are reporting requirements in place that identify new claims as well as the resolution of existing claims -- with severe penalties for non-compliance.
Entities responsible for making payments, such as insurance companies, self-insured entities, and others, must report information about insurance settlements, judgments, and awards to Medicare, and this reporting helps Medicare identify cases where it is the secondary payer so that it may take appropriate action to seek reimbursement.
Conditional Payments are made by Medicare when payment has not been made or cannot reasonably be expected to be made promptly by workers’ compensation, liability insurance (including self-insurance), or no-fault insurance.
A Medicare lien demonstrating Conditional Payments made by Medicare requires all parties to settlement reimburse the Medicare program for payment on past medical services rendered to a beneficiary that were the responsibility of the primary payer.
Conditional payments made by Medicare deemed unrelated to the claim can be formally disputed in writing to the Centers for Medicare and Medicaid Services.
PlanPoint conducts Conditional Payment investigation, analysis, and disputes.
Over its history, PlanPoint has successfully navigated thousands of Conditional Payment investigations, refuting more than 1 million dollars in unrelated care in a single case alone.
PlanPoint can assist you with Conditional Payments and Medicare Liens.
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In 1980, Congress passed legislation that forged the path for Medicare Secondary Payer Compliance or 'MSP'. Congress set out to make Medicare the 'secondary payer' to certain primary plans in an effort to shift costs from Medicare to the appropriate private sources of payment. The MSP provisions have protected Medicare Trust Funds by ensuring that Medicare does not pay for items and services that health insurance or other coverage is primarily responsible for paying.
The MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Medicare statute and regulations require that all entities that bill Medicare for items or services rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those items or services.
This single aspect of Medicare Secondary Payer Compliance, at a high level, is a process ensuring that, as a party to settlement, you are not knowingly making Medicare the primary payer for medical services that would otherwise be paid for by proceeds from settlement.
A Medicare Set Aside or "MSA" is an integral part of Medicare Secondary Payer Compliance. The MSA a document that considers future medical care and apportions the projection of costs therein from proceeds of settlement and includes only future medical services which are considered to be compensable by Medicare. The MSA is the recognized vehicle that quantifies and projects reasonable consideration of Medicare's interests at time of settlement.
PlanPoint proudly continues to operate with decades of MSP experience, successfully executing all facets of Medicare Secondary Payer Compliance, including entitlement investigation, MSA reporting, Conditional Payment analysis, and submission of the MSA report for review and approval with Medicare.
PlanPoint can assist you with all aspects of MSP act related compliance, including MSAs and MSA submission.
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Medical Cost Projections
A Medical Cost Projection or "MCP" is acquired for the specific purpose of identifying the future medical needs and associated costs pertaining to a specific injury claim. No two Medical Cost Projections are alike. The MCP compiles and estimates a total future medical claim value relative to the current course of treatment while it considers any recommendations made by actively treating providers.
The Medical Cost Projection is a document that provides an estimate of items and services that an injured or disabled person will, in all probability, require. The MCP is an impartial, third-party estimate of the costs associated with future medical treatment and includes costs associated with procedures, therapies, medications, durable medical equipment, or other related service stemming from an injury, illness, or condition.
This report is commonly sought by PlanPoint customers for use with reserving, mediation, and settlement negotiations. Please note that the Medical Cost Projection is not suitable for litigation, nor is it to be used for the basis of testimony.
For litigation purposes, a Life Care Plan is the recommended practice. The Life Care Plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs.
PlanPoint can assist you with Medical Cost Projection services.
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Certified Nurse Life Care Planning
The life care plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs.
- International Association of Rehabilitation Professionals (IARP)
Reserved typically for catastrophic claims, a Certified Nurse Life Care Plan goes above and beyond the Medical Cost Projection and is a specialized and meticulously crafted document that combines nursing expertise with a comprehensive life care planning approach. It serves as a critical tool in assessing and addressing the long-term healthcare and related needs of individuals facing chronic illness, injury, or disability.
Certified Nurse Life Care Plans are developed by nurses at PlanPoint who are skilled in evaluating medical conditions, treatment options, and the ongoing care requirements of the individual. Certified Nurse Life Care Planners at PlanPoint meticulously craft each unique plan relying upon their real-world experience and each nurse is dedicated to ensuring the highest quality of care and quality of life for these individuals.
Life Care Planning at PlanPoint includes starts with a comprehensive healthcare assessment and a detailed medical record review followed by thorough research, meticulous analysis, extensive planning, and a strong coordination of efforts between PlanPoint, treating professionals, legal counsel, and the individual, which is then outlined in a complete, easy to read, highly defensible plan of action that has been specifically catered to the individual.
At PlanPoint, we are proud to offer Certified Nurse Life Care Plans, a specialized and highly detailed holistic service that provides individuals, families, and legal professionals with invaluable insights into the complex world of long-term healthcare planning.
PlanPoint can execute Life Care Planning services for you.
Reach out to us, here.